NTI-INFLAMMATORY gluco-
corticosteroids markedly
affect most aspects of
wound healing. When administered sufficiently
early after injury, high corticosteroid levels delay the appearance of inflammatory
cells, fibroblasts, the deposition of ground
substance, collagen, regenerating capillaries, contraction, and epithelial migration.1
Retinoids have the unique ability to
reverse these inhibitory effects, except for
wound contraction. Impairment of the inflammatory response, tensile strength, and
collagen accumulation in cutaneous
wounds after steroid treatment are partially, but significantly, reversed by retinoid administration (retinyl ester, retinol, and/or retinoic acid). 2 Similar
observations were made studying flexor
tendon repair,3 healing of rat femoral frac-
tures,4 vessel repair,5 and healing of intestinal anastomoses.6 Although steroid retardation of healing is a significant clinical
problem and a commonly used laboratory model in the study of repair processes, little is known about the mechanisms of either steroid retardation or
reversal by retinoids.
Retinoids are global regulators of
the growth and differentiation of many
cell types. It is now appreciated that all
actions of retinoids are mediated through
2 families of nuclear receptors belonging
to the steroid hormone receptor superfamily.7,8 These receptors, termed retinoic acid receptors (RARs) and retinoid
X receptors (RXRs), bind and transactivate distinct response elements of
numerous genes required to maintain
differentiation and proliferation of epithelial tissues. The ligand for these
receptors is retinoic acid. Other, more
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both transcriptional and posttranscriptional mechanisms as well as regulation of the activity of the mature
peptides. For example, it has been demonstrated that retinoids control not only the stability of messenger RNAs
encoding the TGF-b isoforms, but also regulate activation of TGF-b from its latent forms,24 and, in certain instances, regulate the expression of the cell surface receptors for TGF-b.7,9 Similarly, retinoids have been shown
to regulate not only synthesis and secretion of the IGFs,
but, in certain cases, synthesis of IGF-binding protein as
well.25
Based on the known antagonistic effects of steroids
and retinoids on wound healing, and on the welldocumented effects of retinoids in regulating the activity
of peptide growth factors, we proposed that steroid
treatment would lower basal levels of TGF-b and IGF-I
and would suppress tissue deposition in wounds. Furthermore, we proposed that retinoids would antagonize
these suppressive effects by their ability to stimulate
corticosteroid-impaired TGF-b and IGF-I release and
thereby stimulate tissue deposition. To test this hypothesis, we have examined the effects of methylprednisolone acetate Depo-Medrol treatment on the levels of
TGF-b and IGF-I in wound fluid and on tissue deposition in wounds, and have assessed the ability of various
retinoids to antagonize this effect.
RESULTS
120
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100
75
Al
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150
er
TGF-, ng/mL
200
TGF-, ng/mL
Steroid-Treated Rats
Control
Rat Group
Rat Group
Figure 2. Transforming growth factor-b (TGF-b) levels in wound fluid at day 17 in all-trans-isomer (A) and 9-cis-isomer (B). Asterisks indicate P,.05, n=48
cylinders per group. See Materials and Methods section for an explanation of the 4 treatment arms of this study.
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150
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IGF-I, ng/mL
iet
IGF-I, ng/mL
100
Rat Group
Rat Group
Figure 3. Insulin-like growth factor-I (IGF-I) levels in wound fluid at day 17 in all-trans-isomer (A) and 9-cis-isomer (B). Asterisks indicates P,.05, n=9 animals
per group. See Materials and Methods section for an explanation of the 4 treatment arms of this study I.
1500
800
1250
600
HOPro, g
HOPro, g
1000
750
400
500
200
250
l-
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Rat Group
Rat Group
Figure 4. Hydroxyproline (HOPro) content in the wound cylinders at day 17 in all-trans-isomer (A) and 9-cis-isomer (B). Asterisks indicate P,.05, n=48 cylinders
per group. See Materials and Methods section for an explanation of the 4 treatment arms of this study.
treated group (Figure 5). As previously shown, systemic retinoic acid alone induced expression of all TGF-b
isoforms in the epidermis in these experiments.10
IMMUNOHISTOCHEMISTRY
The histological features and immunohistochemical staining patterns reflected the biochemical results and showed
the systemic effects of steroid and/or retinoid treatment
on TGF-b expression. At day 17 control sections of the
skin stained with the TGF-b1 antibody showed maximal staining of hair follicles and muscles. Control sections of the skin stained with the TGF-b2 antibody showed
similarly distributed staining of epidermis, dermis, and
muscle. The muscle staining was less pronounced than
in the control sections stained with TGF-b1 antibody.
Control sections of the skin stained with the TGF-b3 antibody showed the maximum intensity of staining in the
epidermis and a granular distribution of the growth factor. Skin sections from animals treated with steroids
showed thinning of the epidermal layer, fewer hair follicles, and less staining of all 3 TGF-b isoforms. Sections of dermal wounds from animals that received supplemental retinoids showed thicker epidermis, more hair
follicles per microscopic field, and intensified staining
for all 3 TGF-b isoforms when compared with the steroid(REPRINTED) ARCH SURG/ VOL 135, NOV 2000
1268
COMMENT
loss. According to the manufacturer, the parenteral retinoid preparations used in earlier experiments, which are
now unavailable, were different mixtures of the various
retinoid metabolites and isomers. The palmitate ester is
metabolized differently than other forms, and this difference rather than the route of administration, in our
opinion, best explains the failure of the parenteral preparation to share the vulnerary results of the orally given
forms.
The immunohistochemical studies were performed for 2 reasons. First, it was necessary to demonstrate that the animals had developed significant systemic effects of the steroids despite the short treatment
duration. Second, we wished to test a long-held hypothesis that systemic retinoids given in treatment of steroidsuppressed repair might diminish the therapeutic potential for which the steroids are being given. Clearly, the
animals were significantly affected, and there is potential for diminishing the desired effects of steroid therapy.
These observations raise several caveats. First, treatment of wound failure in this circumstance should be cautious when interruption of steroid effect might become
problematic. Local retinoid therapy to wounds is also clinically effective. Second, systemic use should be shortWWW.ARCHSURG.COM
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